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Based on policy and procedure review, medical record reviews, Security Incident Report review, and staff interview the hospital failed to provide stabilizing treatment for a sampled Dedicated Emergency Department (DED) patient, (Patient #6).

The findings include:

The hospital failed to provide stabilizing treatment as required for a sampled DED patient (Patient #6).

~cross refer to Stabilizing Treatment, Tag A 2407.

Based on policy and procedure reviews, closed medical record reviews, and Security Incident Report, and interviews, the facility failed to ensure hospital's dedicated emergency department (DED) provided stabilizing treatment as required for one (1) of 4 sampled DED patients presenting with psychiatric issues, (Patient #6).

The findings included:

Review of the hospital policy titled "Emergency Medical Treatment and Labor Act (EMTALA), 13.0" with a revision date of 04/2020 revealed "... 1. All patients who come to the Emergency Department seeking treatment will be provided with an appropriate medical screening examination to determine whether or not the patient has an emergency medical condition ... 2. If the medical screening exam reveals that an emergency medical condition exits, ... will then provide all such patients with treatment necessary to stabilize the condition ... Stable Patients: If a patient's Emergency Condition is Stabilized, the patient can be discharged or transferred ... A patient is considered stable when the treating physician has determined, with reasonable clinical confidence, that the Emergency Medical condition has been resolved. Unstable Patients: An unstable patient can only be transferred under one of the following conditions: 1. Medically indicated ... 2. Patient request transfer ... Appropriate Transfer: An appropriate transfer is defined as: 1. ... provided medical treatment, within its capacity, that minimizes the risk to the patient's health ... 2. The receiving facility has available space and qualified staff for the treatment of the patient and has agreed to accept transfer of the individual and to provide appropriate medical treatment. A physician at the receiving hospital has agreed to accept the patient ..."

The facility's policy titled "Admission, Continued Stay and Discharge Criteria- Psychiatric Inpatient Department' Origination 01/2019, Last reviewed 11/2020 was reviewed. The policy revealed in part, "a. Admission Criteria- There is evidence of actual or potential danger to self and others or severe psychosocial dysfunction as evidenced by at least one of the following:
1. A suicide attempt which is serious by degree of lethality and intention, or suicidal ideation with a plan and means. Impulsive behavior and/or concurrent intoxication increase the need for consideration of this level of care. . .
2. Current assault threats, resulting from axis 1 disorder (mental health and substance abuse disorder), with a clear risk of escalation or future repletion (i.e. has a plan or means) ...

Review of a closed medical record revealed Patient #6 was a 41-year-old male that was brought to the hospital on 04/18/2022 at 1:36 P.M., via EMS (emergency medical service) with a chief complaint of suicide ideation (thoughts of suicide) by overdose. Medical record review revealed Patient #6 had a history of manic depression and multiple suicide attempts. Medical record review revealed at 2:25 P.M., Registered Nurse (RN) #17 triaged (Triage- the sorting of patients as in the Emergency Room according to their needs) Patient #6 as a level 2 (Emergent). RN #17 also documented Patient #6 was a "High Risk" for suicide based on the "Columbia Suicide Severity Rating Scale" (suicide ideation rating scale). Review of an "Emergency Department Note" signed by RN#17 on 04/18/2022 at 2:35 P.M. revealed "... charge nurse aware of pt. (patient) will be placed in room when available ..." Review of an "Emergency Department Note" signed by Certified Nursing Assistant (CNA) #19 on 04/18/2022 at 4:18 P.M., (2 hours, 21 minutes after Patient #6's arrival to ED) revealed "Received a call from ... with Mobile Crisis letting staff know the patient called him and said he got his pills back and was going to take them all. Staff alerted the RN in triage and Charge Nurse." Review an "Emergency Department Note" signed by the charge nurse (RN #18) on 04/18/2022 at 4:25 P.M. (2 hours, 29 minutes after arrival to ED) revealed "Patient locked himself in lobby bathroom with his home meds which were given to him by EMS which was unknown to this RN. Security notified immediately and to bathroom to unlock door ... Nurse Practitioner with Psych and MD notified of the same. Emergency IVC (Involuntary Commitment- magistrate may issue an order to take a person into custody for examination by a qualified professional. If the qualified professional finds the person is mentally ill and dangerous to themselves and others he/she will be taken to a hospital https://www.ncdhhs.gov) papers to be completed." Medical record review revealed on 04/18/2022 at 5:15 P.M., Patient #6 was placed in room #13 in the emergency department. The patient was still refusing to give up belongings and medications. The patient was monitored and placed on 1:1 by staff until successful removal of medications. At 6:00 P.M. Patient belongings and medications were retrieved and documented. The state of North Carolina Supplement to examination of Recommendation for Involuntary Commitment (IVC) dated 4/18/2022 at 6:15 P.M., for patient #6 was reviewed. The document revealed in part, "... SUPPLEMENT TO SUPPORT IMMEDIATE HOSPITALIZATION ...Certificate the Respondent Patient #6 requires immediate hospitalization to prevent harm to self and others because threatened suicide by overdose on home medications ... I certify based on my examination of the Respondent ...The Respondent is mentally ill and dangerous to self."
Further review of the Emergency Room Note revealed documentation by ED Nurse on 4/19/22 at 9:42 A.M., paper work was faxed to magistrate to receive a custody order. The RN taking care of patient #6 will be updated once all the paperwork is completed. On 4/19/22 at 11:30 A.M. the RN documented the patient was yelling and cursing staff and attempting to roll his wheelchair out to the EMS ambulance bay. Security was notified and responded. The MD was also notified. At 12:06 P.M., the RN documented again the patient was attempting to elope by rolling his wheelchair the EMS doors. Security was called and patient taken back to his room. On 4/19/22 at 1:15 P.M. the ED Nurse #18 documented in part, "Odor of cigarette smoke noted coming from ED bathroom near Hallway 2. Staff responded and found the door to be locked. Patient refusing to come to door and refusing to unlock same. Security called to unlock the door. Upon entering the bathroom, patient found sitting on the toilet and strong odor of smoke noted. Wheelchair removed from bathroom and searched. Pill bottle found with several random pills, cigarettes, lighter, and cell phone all under wheelchair seat. The patient became aggressive with nursing staff, security and Physician Assistant. Patient attempting to punch staff and throwing his wheelchair at staff. Wheelchair removed from patient and patient assist to hospital stretcher. After on stretcher, Pt. kicked PA in the stomach and continued to attempt to punch staff. Pt. medicated per orders." Further documentation revealed that patient #6 was placed in 4 points restraints. The reason restraint was initiated because the patient was combative, potential for self-harm, physical self-harm, potential harm to others and Physical violence.

Review of the "Psychiatric Consult" note dated 04/18/2022 at 5:28 P.M., for patient #6 revealed in part, " ...Psychiatric Chief complaint ... 41-year-old homeless male who presents to the ED with complaints of SI (Suicidal Ideations) stating he has nothing to live for, has no where to stay and has no family. Reports he needs to get into an inpatient mental health facility where he can get back on his medications correctly ...Reports he plans to overdose on all his medications if he is not admitted to a facility he does have all his medications with him not limited to Seroquel (used to treat certain mental/mood conditions), Lamictal (Medication used to treat Bi-polar disorder, anxiety and depression), Buspar and Valium (medications used to treat anxiety), He reports that this time he is not here for housing... He continues to endorse SI with a plan to overdose. Reports multiple suicide attempts.... will admit to the ED at this time for SI, will restart the patient home medications which he has brought in with him ..." Review of the patient's mental examination revealed the patient's appearance was obese and disheveled, Affect: Congruent/Mood and Judgement Impaired. Continued review of the "Psychiatric Consult" note dated 04/19/2022 at 1823 revealed "Plan to refer outpatient to another facility as there are no available beds here on the 6th floor behavioral health unit. Update-patient has assaulted staff member and is to be transported to jail. Patient is endorsing SI however secondary gain is noted, cannot rule out malingering, will recommend that he be transferred to jail but kept under suicide precautions while there, as he has a history of suicide attempt ..."

Review of the "Emergency Room Provider Record" dated 4/18/22 at 7:05 P.M., revealed that patient #6 presented to the ED with complaints of Suicidal Ideations, reports has had worsening of depression, and on presentation locked himself in the bathroom, and was going to overdose on pills. Prior Psychiatric history of Bi-polar, Depression, and associated symptoms Depression, Suicidal thoughts. Further review revealed a Physical examination was completed and Laboratory tests reviewed. Documentation revealed in part, Primary Impression: Depression. Additional Impression: Urinary Tract Infection, Suicidal Ideation. Disposition Type: Hospitalize ED BH (Emergency Department Behavioral Health Unit)." Review of the "Emergency Room Provider Record" dated 04/19/2022 at 6:03 P.M., revealed "... Reviewed psychiatrist's note. There was suspicion that patient is malingering (it refers to producing false medical symptoms or exaggerating existing symptoms in hopes of being rewarded in some way. https://healthline.com) or secondary gain. Patient assaulted staff member and also attacked LEO (Law Enforcement Officer). Patient is being discharged to jail with suicide precaution ... Primary Impression: Depression Additional Impressions: Urinary tract infection, Suicidal ideation Disposition Type: Discharge (to jail with suicide precautions) Condition: Stable." Medical record review revealed on 04/19/2022 at 8:02 P.M. Patient #6 was discharged to a jail/detention facility.

Review of a "Security Incident Report" dated 04/19/2022 at 1:15. P.M. revealed ... was called to the back for patient in room #13. Patient had been missing for over half and [sic] hour where he was found locked up in the bathroom with the smell of cigarettes all in the air ..."

According to review of the facility's, policy and procedure revealed that on 4/19/2022 patient #6 required and met in-patient hospital criteria; due to evidence of actual danger to self and others. Additionally, there was evidence of Suicidal ideations with a plan and means. The facility failed to ensure that on 4/19/22 that patient #6 was stabilized as required and admitted to an inpatient psychiatric hospital and not discharged for incarceration. The patient was still suicidal. There was no documentation in the medical record to indicate that the facility ED staff attempted to transfer the patient to an inpatient Psychiatry facility for psychiatric care and treatment. The IVC dated 4/18/22, stated that patient #6 needed immediate in-patient psychiatric treatment.

Telephone interview on 05/19/2022 at 1435 with Physician Assistant (PA) #21 revealed she believed Patient #6 was stable for discharge based on the patient's past behaviors and history of malingering. Interview revealed Patient #6 reported a plan to overdose on his home medications but did not have access to the meds at the time he was being discharged from the ED. Interview revealed some patients know what to say in order to stay at the hospital for shelter and food. Interview revealed PA #21 believed Patient #6 was safe for discharge to jail with suicide precautions.

Telephone interview on 05/19/2022 at 1500 with an ED physician (MD #22) revealed Patient #6 had been seen in the ED multiple times and there was concern from the staff the patients was there for "secondary gains." Interview revealed MD #22 believed Patient #6 was stable for discharge to jail with suicide precautions.